Healthcare Provider Details

I. General information

NPI: 1871799585
Provider Name (Legal Business Name): ANGEL NICOLE HEYERLY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

3825 E 800 N
OSSIAN IN
46777-9622
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7441
  • Fax: 260-435-7609
Mailing address:
  • Phone: 260-622-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26020571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: